ATI RN PROCTORED Nursing Care of Children 2019 A & B
Nursing Care of Children 2019 A
1. A nurse is providing education to the parent of a child who has cystic fibrosis and has a
prolapsed rectum. The nurse should teach that which of the following is a cause of this
complication:
a. Bulky stools
b. Weakened rectal sphincter
c. Elevated pancreatic enzymes
d. Decreased intra abdominal pressure
Answer: a. Bulky stools
2. A pre-schooler is admitted to the emergency department with full thickness third degree burn
over 45% of his body. Which of the following actions should the nurse take first:
a. Administer IV morphine
b. Administer IV antibiotics
c. Administer IV solutions
d. Administer total parenteral nutrition
Answer: c. Administer IV solutions
3. A nurse is providing teaching to a parent of a pre-schooler who has Tinea Capitis. Which of
the following should the nurse include in the teaching:
a. Apply 1 to 20 burrow’s solution compressed to the lesions
b. Apply hydrocortisone cream to the lesions twice daily
c. Seal and wash toys in plastic bag for two weeks
d. Leave the shampoo on the scalp for 5 to 10 minutes
Answer: d. Leave the shampoo on the scalp for 5 to 10 minutes
4. A nurse is caring for a child who has sickle cell anemia. Which of the following signs of acute
chest syndrome should the nurse report to the primary care provide immediately:
a. Congestive cough
b. Dilute hearing
c. Hct of 10g/dl
d. Systolic murmur
Answer: a. Congestive cough
5. A nurse is assessing a 3month old infant for suspected intussusception. Which of the following
findings should the nurse expect:
a. Jelly-like stool
b. Board-like abdomen
c. Projectile vomiting
d. Oliguria
Answer: a. Jelly-like stool
6. A nurse is planning a teaching session for parents regarding infant development. Which of the
following parent activities regarding play should the nurse include in the teaching:
a. Encourage the infant in one on one play
b. Promote play with other infants
c. Provide visual stimulation with pastel colored toys
d. Give the infant a large piece puzzle
Answer: a. Encourage the infant in one on one play
7. A school-aged child with sickle cell anemia has been admitted in vaso- occlusive crisis. Which
of the following assessment findings should the nurse recognize as an emergency?
a. Slurred speech
b. Fever of 38.30 C (1010 F)
c. Hematuria
d. Pain level of 7 on a faces scale
Answer: a. Slurred speech
8. A nurse in an emergency department is assessing a child who was in a motor vehicle accident.
Which of the following assessment findings require immediate intervention:
a. Dilated and fixed pupils
b. Disorientation to person and place
c. Positive Babinski reflex
d. Restless and irritable
Answer: a. Dilated and fixed pupils
9. A nurse is assessing a child who has sustained a head injury. During the assessment, the nurse
observes clear drainage leaking from the child’s nose. Which of the following actions should the
nurse take?
a. Perform naso-tracheal suctioning
b. Test the nasal secretions for glucose
c. Maintain direct lighting on the child
d. Lower the head of the bed
Answer: b. Test the nasal secretions for glucose
10. A nurse at a provider’s office is preparing a newborn for a routine heel puncture. Which of
the following actions should the nurse take?
a. Administer tolectin (tolmetin) prior to the procedure
b. Apply EMLA cream to the heel after the procedure
c. Prepare concentrated sucrose for oral administration
d. Place the new born in an extended position
Answer: c. Prepare concentrated sucrose for oral administration
11. A nurse is caring for a child who has rheumatic fever. Which of the following is an indication
that the child has developed carditis?
a. Carotid bruit
b. Chest pain
c. Hypotension
d. Cyanosis
Answer: b. Chest pain
12. A parent calls the clinic asking for pinworm testing information, the nurse should advise the
parent to perform the test at which of the following times?
a. Immediately after child has a bowel movement
b. After being on a clear diet for 24hrs
c. Immediately after the child awakes in the morning
d. After soaking for 20 minutes in a warm bath
Answer: c. Immediately after the child awakes in the morning
13. A nurse is educating the parents of an infant who has mild gastroesophageal reflux. Which
dietary adjustment should the nurse recommend?
a. Provide a little sprout formula
b. Administer nasogastric feedings
c. Thicken feedings with rice cereal
d. Place infant in a lateral position for one hour after feedings
Answer: c. Thicken feedings with rice cereal
14. A nurse is teaching an adolescent client about managing asthma and using a peak respiratory
flow meter. Which of the following by the client demonstrates an understanding of the teaching:
a. I will use my peak flow meter whenever I feel short of breath
b. I will continue to take my medication when my peak flow meter is in the green zone
c. I need to use the average of three readings when I measure my flow rate
d. My asthma is being controlled if my flow rate is in the yellow zone
Answer: b. I will continue to take my medication when my peak flow meter is in the green zone
15. A nurse is instructing the parent of an infant who has clubfeet and has cast applied. Which of
the following statements by the parent indicates a need for further teaching:
a. My baby will need to return to have his cast changed weekly
b. I need to check my baby’s toes for any discolorations daily
c. My baby will need to have surgery at 18 months if his toes aren’t fixed
d. I will check the skin around my baby’s cast at every diaper change.
Answer: c. My baby will need to have surgery at 18 months if his toes aren’t fixed
16. A nurse assesses an infant that is admitted for acute gastroenteritis. Which of the following is
the priority finding?
a. Decreased tears
b. Capillary refill of 5 seconds
c. Heart rate 150/min
d. Dry mucous membranes
Answer: b. Capillary refill of 5 seconds
17. A nurse is planning to teach a nutrition class for preschoolers. Which of the following is an
appropriate instructional strategy? (Select all that apply.)
a. Offer written handouts
b. Limit the teaching session to 45 minutes
c. Use simple language
d. Incorporate games into the lesson
e. Provide concrete examples
Answer: b. Limit the teaching session to 45 minutes
c. Use simple language
d. Incorporate games into the lesson
e. Provide concrete examples
18. A nurse is caring for a toddler who has a fever, high-pitched cry, irritability and vomiting.
Which of the following is an appropriate action for the nurse to take?
a. Administer 81mg of Aspirin
b. Place the toddler in a cold water bath
c. Place the toddler in a supine position
d. Pad the rails of the bed
Answer: d. Pad the rails of the bed
19. A nurse is reviewing the morning lab results for an infant who is receiving Digoxin and Lasix
for the treatment of heart failure. Which of the following should the nurse report to the provider:
a. Sodium 140 mEq/L
b. Calcium 10.2 mg/dL
c. Chloride 100 mEq/L
d. Potassium 3.2 mEq/L
Answer: d. Potassium 3.2 mEq/L
20. A nurse is caring for a school aged child who has an arm cast applied 8 hours ago. Which of
the following findings should alert the nurse of complications related to the casting:
a. Child rates pain of 5 on a scale from 0 to 10
b. Child’s hands are cool bilaterally
c. Child reports tightness at the wrist
d. Child grasp is weak
Answer: c. Child reports tightness at the wrist
21. A nurse is performing a neurological examination on a 15-month-old child.
Which of the following is an expected normal finding?
a. Negative Babinski reflex
b. Presence of Moro reflex
c. Absence of corneal reflexes
d. Positive palmar grasp
Answer: a. Negative Babinski reflex
22. Which of the following actions indicates to the nurse that the parent of a preschooler is using
an age-appropriate disciplinary technique?
a. Explains to the child why her behavior is unacceptable?
b. Places the child in time out after misbehaving
c. Allows the child to choose the consequence for her misbehavior
d. Assigns an extra chore for the misbehavior
Answer: c. Allows the child to choose the consequence for her misbehavior
23. A nurse is caring for an infant who is pre-operative for the treatment of mild
myelomeningocele. In which of the following positions should the nurse place the infant:
a. Side-lying
b. Supine
c. Prone
d. Semi-Fowlers
Answer: c. Prone
24. A nurse is providing postoperative care for an infant who has pyloric stenosis. Which of the
following actions should the nurse take?
a. Use a re-breather mask to provide oxygen
b. Place the infant in a supine position
c. Initiate feedings with clear fluids
d. Weigh the infant every 48 hours
Answer: c. Initiate feedings with clear fluids
25. A nurse is admitting a child with tonic clonic seizures. Which of the following is the priority
to have in the room:
a. Pulse ox meter
b. Oxygen therapy
c. Valve mask
d. Suction equipment
Answer: d. Suction equipment
26. An infant has had a cardiac catheterization with a right femoral entry to diagnose a possible
congenital heart defect. Following this procedure, the nurse should be concerned about which of
the following:
a. Cool toes on the right foot
b. Weak pedal pulses on both feet
c. Positive Babinski on both feet
d. Erythema on the right foot
Answer: a. Cool toes on the right foot
27. A nurse is developing a health program for the parents of school age females. Which of the
following regarding sexual maturation should the nurse include:
a. Higher body fat content is often highly associated with earlier onset of menarche
b. Pubic hair is typically present prior to breast development
c. Ovulation begins after sexual maturation is complete
d. Menarche signals the beginning of puberty
Answer: c. Ovulation begins after sexual maturation is complete
28. A nurse is assessing a child who has measles (rubella). Which of the following findings
should the nurse expect?
a. Vesicular rash
b. Koplik spots
c. Para oximal
d. Sternal retractions
Answer: b. Koplik spots
29. On the way to the emergency department a parents reports a child accidentally ingested
overdose acetaminophen. Which of the following medications should the nurse prepare to
administer?
a. Naloxone
b. Diphenhydramine
c. Glucagon
d. Acetylcysteine
Answer: d. Acetylcysteine
30. A nurse preceptor is working with a newly licensed nurse in caring for a child that is
postoperative for a placement of a tracheaosophageal shunt. Which of the following statements
made by the newly licensed nurse indicates a need of further teaching:
a. I will ensure that pressure is not applied to the shunt valve
b. I will pump the shunt every two hours
c. I will keep the head of the bed flat for two hours
d. I will offer prescribed pain medication as needed
Answer: a. I will ensure that pressure is not applied to the shunt valve
31. A nurse is teaching the parents of a toddler who has a new prescription for an oral iron
supplement. Which of the following should the nurse recommend for administration with the
medication to increase its absorption:
a. A protein source
b. Orange juice
c. Milk
d. A whole grain fiber
Answer: b. Orange juice
32. A nurse is evaluating the anticipatory grieving of a parent do to the impending loss of a child.
Which response indicates a need for further assessment by the nurse:
a. “We will encourage our other children to be involved in the care of our child.”
b. “We have contacted hospice to ensure our child does not have pain.”
c. “We understand our child will be most comfortable in a hospital.”
d. “We have given our child permission to die.”
Answer: c. “We understand our child will be most comfortable in a hospital.”
33. A nurse is assessing an adolescent female. The adolescent’s mother tells the nurse she is
concerned that her daughter is too thin. Which of the following assessment findings are
consistent with anorexia nervosa?
a. Hyperactive deep tendon reflexes
b. Lanugo over the back
c. Oily skin with acne
d. Elevated body temperature
Answer: b. Lanugo over the back
34. A nurse is educating the family of a child regarding hospice care. Which of the following
should the nurse include in the teaching:
a. “The hospice staff will be the primary care giver of this child.”
b. “Hospice staff consider the needs of the family as important as those of this child.”
c. “Hospice care will end with the death of the child.”
d. “The priority of hospice care is to provide curative treatment for the child.”
Answer: b. “Hospice staff consider the needs of the family as important as those of this child.”
35. A nurse is caring for a child who has acute renal failure. Which of the following findings is of
priority concern to the nurse?
a. Hyperphosphatemia
b. Hyponatremia
c. Hypocalcemia
d. Hyperkalemia
Answer: d. Hyperkalemia
36. A nurse is caring for a breast-feeding infant who is given amoxicillin for an upper respiratory
infection. Assessment of the mouth reveals white patches that would not scrape off. Which of the
following nursing interventions is appropriate?
a. Offer the infant water before feedings
b. Discontinue the amoxicillin
c. Administer antifungal medication after feedings
d. Give the infant formula instead of breast milk
Answer: c. Administer antifungal medication after feedings
37. A nurse is caring for an infant admitted with hydrocephalus, and increased intracranial
pressure. Which of the following findings should the nurse expect?
a. Decreased occipital frontal circumference
b. A depressed fontanel
c. Unresponsive to physical stimuli
d. A high-pitched cry
Answer: d. A high-pitched cry
38. A nurse is caring for a toddler who is postoperative following the repair of a cleft palate.
Which of the following interventions by the nurse is appropriate?
a. Restrain arms at the elbows
b. Feed with a spoon
c. Monitor oral temperature
d. Provide pacifier for comfort
Answer: a. Restrain arms at the elbows
39. A parent of an infant who is taking Digoxin (Lanoxin) phones the nurse at a clinic because
the child has vomited the medication. Which of the following is the priority nursing
intervention?
a. Tell the father that a repeat dose of medication should not be given
b. Verify the prescribed medication regimen
c. Determine if the infant has been exposed to others who are ill
d. Ask the father about the infant’s urinary output.
Answer: a. Tell the father that a repeat dose of medication should not be given
40. A nurse is providing teaching to the parents of a toddler about injury prevention. Which of
the following safety measure should the nurse include in the teaching?
a. Select the toy box with the heavy hand slid
b. Provide balloons for play
c. Check clothing for loose buttons
d. Offer grapes as a snack food
Answer: c. Check clothing for loose buttons
41. A nurse at a pediatric clinic assessing the fluid in caloric intake for an infant who weighs 5 kg
and fed a commercial infant formula. The provider recommends that the infants eat just at least
2.5 mg of formula per kg/day, and the formula contains 20 calories per ounce. What is the
minimum number of calories per day the infant should consume?
Answer: 550 Calories
42. A nurse is preparing to administer Tolumedrol IV bolus to a child who weighs 88 pounds.
The provider prescribes 1.5 mg/kg/day to administer twice daily. Available is the solumedrol 20
mg/ml. How many ml should the nurse administer with each dose? (Round the answer to the
nearest tenth.)
Answer: 1.5 ml
43. A nurse is assessing an infant with appendicitis, which of the following are expected
findings? Select all that apply
a. Vomiting
b. Jaundice
c. Bradycardia
d. Right lower quadrant pain
e. Fever
Answer: a. Vomiting
d. Right lower quadrant pain
e. Fever
44. A nurse is caring for a child who received penicillin IM 15 minutes ago. The child is now
irritable and restless. Which of the following is the priority action for the nurse to take?
a. Administer diphenydramine
b. Assess for laryngeal edema
c. Initiate continuous ECG monitoring
d. Give Epinephrine IV push
Answer: b. Assess for laryngeal edema
45. A nurse is providing teaching to the parents of a 9-month-old infant who is suspected of
having spastic cerebral palsy. Which of the following statements is appropriate for the nurse to
make?
a. “Use an infant walker to increase you baby’s mobility.”
b. “Your baby may loose appetite.”
c. “Physical therapy will be implemented to reduce contractures.”
d. “Your baby’s immunization schedule will be altered.”
Answer: c. “Physical therapy will be implemented to reduce contractures.”
46. A nurse is reviewing a school-aged child’s family’s health history. Which of he following
indicates a need to obtain lipid screening for the child:
a. Grand parent has type 1 Diabetes Mellitus
b. Sibling who has cystic fibrosis
c. Parent who has high cholesterol
d. Parent who has cardiac dysrhythmia
Answer: c. Parent who has high cholesterol
47. A nurse is providing discharge teachings for the parents of a child who has leukemia and is
receiving vincristine. Which of the following should the nurse include in the teaching:
a. Keep the child out of the sun
b. Increase the child’s intake of fluids
c. Monitor the child’s heart rate
d. Assess the child for epistaxis
Answer: b. Increase the child’s intake of fluids
48. A nurse is caring for an infant who has tracheal esophageal fistula. Which if the following is
an appropriate action for the nurse to take?
a. Position the infant prone
b. Prepare the infant for surgery
c. Administer zantac
d. Thicken the infants formula
Answer: b. Prepare the infant for surgery
49. A phone triage nurse is talking to the parents of a toddler who states, “My child has placed a
bead in his nose and I don’t know what to do”. Which of the following is an appropriate response
by the nurse:
a. Try removing the bead using a pair of tweezers
b. Take your child to the pediatrician in the morning
c. Take your child to the emergency department now
d. Have your child blow his nose to dislodge the bead
Answer: c. Take your child to the emergency department now
50. A nurse is teaching an adolescent who has a prescription for nystatin (Troche) orally. Which
of the following should the nurse include in the teaching:
a. “Rinse immediately following the troche.”
b. “You should avoid taking the troche with milk.”
c. “Avoid taking anything by mouth 30 mins after taking the troche.”
d. “You should chew the troche completely.”
Answer: c. “Avoid taking anything by mouth 30 mins after taking the troche.”
51. A nurse is caring for a child who has a tracheostomy, which of the following techniques
should the nurse to suction the child?
a. Insert the catheter 2cm beyond the end of the tracheostomy tube
b. Remove the catheter while applying intermittent suction
c. Instill saline to loosen secretions while suctioning
d. Continue suctioning until the secretions are removed
Answer: b. Remove the catheter while applying intermittent suction
52. A toddler is admitted to the hospital with gastroenteritis and positive for a rotavirus. For
which of the following should the nurse wear a gown and don gloves?
a. Delivering the food tray
b. Administering medication
c. Assessing the IV site
d. Changing the bed linens
Answer: d. Changing the bed linens
53. A nurse is caring for a child who is postoperative, which of the following findings indicates
the need for administration of naloxone?
a. Crackles in the lung bases
b. Respiratory depression
c. Nausea and vomiting
d. Tachycardia
Answer: b. Respiratory depression
54. A nurse is assessing a 3-year-old client. Which of the following developmental milestones
should the nurse expect the child to demonstrate?
a. Stacking 8 blocks
b. Printing one to two letters
c. Tying shoe laces
d. Using seven word sentences
Answer: a. Stacking 8 blocks
55. A nurse is caring for an adolescent following a lumbar puncture. Which of the following is an
appropriate action for the nurse to take?
a. Initiate NPO status
b. Place the client in a supine position
c. Place a moist warm pack on the lower back
d. Apply and eutectic mixture local anesthetics to the puncture site
Answer: b. Place the client in a supine position
56. A nurse is planning care for a toddler admitted with acute gastroenteritis. Which of the
following should the nurse expect to give?
a. Oral rehydration solution
b. Bananas or apple sauce
c. Chicken or beef broth
d. Hypertonic IV solutions
Answer: a. Oral rehydration solution
57. A toddler diagnosed with Tetralogy of Fallot becomes hypercapnic with worsening cyanosis.
Which of the following actions should the nurse take first?
a. Place the toddler in knee chest position
b. Initiate Iv fluid replacement
c. Provide 100% oxygen by face mask
d. Administer morphine
Answer: a. Place the toddler in knee chest position
58. A child admitted for acute nephrotic syndrome had been receiving prednisone by mouth for
the past week. After reviewing the child’s lab results, which of the following should the nurse
report to the primary care provider?
a. Serum sodium 142 mEq/L
b. Serum potassium 4.0 mEq/L
c. White blood cell count 3,000 mm3
d. Platelet count of 298,000/L
Answer: c. White blood cell count 3,000 mm3
60. A nurse is providing education to the parents of an infant who is being treated with Pavlik
harness. Which of the following actions is appropriate when teaching the parents about home
care measures:
a. Adjust the infant’s harness once a week
b. Ensure the infant wears the shirt under the harness
c. Apply powder on harness after bathing
d. Maintain the infant in an upright position
Answer: b. Ensure the infant wears the shirt under the harness
61. A nurse is caring for an infant who is in the last stage of neuroblastoma. The parents ask,
“How can we best help our child now?” Which of the following responses by the nurse is
appropriate?
a. “Encourage you child’s friends to visit.”
b. “Stay close to your child.”
c. “Allow your child to see you cry.”
d. “Talk to your child about the meaning of death.”
Answer: b. “Stay close to your child.”
62. A nurse is providing teaching to the parents to a school age child following the placement of
a ventricular peritoneal shunt. This nurse understands teaching has been effective when the
parents identify which of the following as an indication that the shunt has been displaced?
a. Decreased urine output
b. Decreased head circumference
c. Elevated temperature
d. Increased sleeping
Answer: c. Elevated temperature
63. A nurse is caring for a 4 year old child. After reviewing the chart, which of the following is
an appropriate action for the nurse to take? (Click on the exhibit below for additional
information)
a. Insert a nasogastric tube for suctioning
b. Palpate the child’s abdomen for rebound tenderness
c. Prepare the child for abdominal CT scan
d. Initiate a diet high in protein and calories
Answer: c. Prepare the child for abdominal CT scan
64. A nurse is caring for an adolescent who is receiving fentanyl via epidural route. Which of the
following is a priority action for the nurse to take:
a. Assess skin around the catheter site
b. Check blood pressure
c. Assess pain level
d. Check oxygen saturation
Answer: d. Check oxygen saturation
65. A nurse in an acute care facility is caring for a 14-month old toddler who has E.coli. Which
of the following actions is appropriate for the nurse to take?
a. Administer opioids for pain
b. Give an oral antidiuretic agent
c. Implement a BRAT diet
d. Initiate contact precautions
Answer: d. Initiate contact precautions
66. A nurse is providing teaching to the parents of a toddler with failure to thrive. Which of the
following should the nurse include in the teaching:
a. Hold the infant face to face to maintain eye contact
b. Alternate things between several family members
c. Introduce several new foods to stimulate the infant’s interest
d. Provide a stimulating infant to keep the infant awake
Answer: a. Hold the infant face to face to maintain eye contact
67. A nurse is providing discharge teaching to the parent of a child who experienced status
asthmaticus. Which of the following responses by the parent indicates an understanding of the
teaching?
a. “I will perform chest physiotherapy during an acute attack.”
b. “When using a metered-dose inhaler, my child should inhale the quickly exhale medication.”
c. “My child will use his bronchodilator before bedtime to prevent wheezing.”
d. “I will call the doctor if my child becomes anxious and restless at night.”
Answer: d. “I will call the doctor if my child becomes anxious and restless at night.”
68. A 10-month-old infant is undergoing a well infant check up. Which of the following
assessment findings should concern the nurse?
a. The infant is unable to walk alone
b. The infant’s Moro reflex is absent
c. The infant’s anterior fontanel was opened
d. The infant needs assistance to sit up
Answer: d. The infant needs assistance to sit up
69. A nurse is communicating with a child who has hearing loss. Which of the following actions
should the nurse take?
a. Exaggerate pronunciation of words
b. Change positions frequently to maintain attention
c. Use touch to initiate communication
d. Avoid using facial expressions when speaking
Answer: c. Use touch to initiate communication
70. An early school aged child continues to have mild discomfort after administration of an
analgesic. Which of the following actions should the nurse use?
a. Use guided imagery
b. Give the child a large coconut to find different designs
c. Encourage the child to take a deep breath
d. Teach the child to picture a stop sign whenever the pain begin
Answer: a. Use guided imagery
Nursing Care of Children 2019 B
Question - 1
A nurse is creating a plan of care for a school-age child who has heart disease and has developed
heart failure. Which of the following interventions should the nurse include in the plan?
Answer: Provide small, frequent meals for the child. The metabolic rate of a child who has heart
failure is hight because of poor cardiac function. Therefore, the nurse should provide small,
frequent meals for the child because it helps to conserve energy.
Question - 2
A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of
developmental dysplasia of the hip. The nurse should identify that which of the following
statements by the parent indicates an understanding of the teaching?
Answer: "I will place my infant's diapers under the harness straps". To prevent soiling of the
harness, the parent should apply the infant's diaper under the straps.
Question - 3
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury
(AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the
nurse include in the plan?
Answer: Initiate seizure precautions for the child. A sodium level of 129 mEq/L indicates
hyponatremia and places the child at increased risk for neurological deficits and seizure activity.
The nurse should complete a neurologic assessment and implement seizure precautions to
maintain the child's safety.
Question - 4
A nurse is assessing a school-age child immediately following a perforated appendix repair.
Which of the following findings should the nurse expect?
Answer: Absence of peristalsis. The nurse should expect absence of peristalsis immediately
following a perforated appendix repair, until the bowel resumes functioning.
Question - 5
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should
the nurse take?
Answer: Apply topical analgesic cream to the site 1 hr prior to the procedure. The nurse should
apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the
adolescent's pain while the lumbar needle is inserted.
Question - 6
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The
child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the
medication infusion, which of the following medications should the nurse administer first?
Answer: Epinephrine. This child is most likely experiencing an anaphylactic reaction to the
cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to
treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes
vasoconstriction of blood vessels in the skin and mucous membranes, and triggers
bronchodilation in the lungs.
Question - 7
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks.
Which of the following statements by the parent indicates an understanding of the teaching?
Answer: "I should keep my child indoors when I mow the yard’’. The nurse should instruct the
parent to keep the preschooler indoors during lawn maintenance or when the pollen count is
increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and
weed pollen, will decrease the frequency of the preschooler's asthma attacks.
Question - 8
A nurse is proving dietary teaching to the parent of a school-age child who has celiac disease.
The nurse should recommend that the parent offer which of the following foods to the child?
Answer: White rice. The nurse should recommend that the parent offer white rice to the child
because it is a gluten-free food. The nurse should instruct the parent that the child will remain on
a lifelong gluten- free diet and the child should not consume oats, rye, barley, or wheat, and
sometimes lactose deficiency can be secondary to this disease.
Question - 9
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue.
Which of the following findings should the nurse recognize as an indication of anemia?
Answer: Hematocrit 28%. The nurse should recognize that this hematocrit level is below the
expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue,
lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity.
Question - 10
A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the
following actions should the nurse plan to take?
Answer: Perform a finger stick. The nurse should perform a finger stick on a toddler as a
component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is
required to distinguish between children who have the genetic trait and children who have the
disease.
Question - 11
A nurse is assessing a school-age child who has meningitis. Which of the following findings is
the priority for the nurse to report to the provider?
Answer: Petechiae on the lower extremities. The presence of a petechial or purpuric rash on a
child who is ill can indicate the presence of meningococcemia. This type of rash indicates the
greatest risk of serious rapid complications from sepsis and should be reported immediately to
the provider.
Question - 12
A nurse is assessing an infant who has a ventricular septal defect. Which of the following
findings should the nurse expect?
Answer: Loud, harsh murmur. The nurse should expect to hear a loud, harsh murmur with a
ventricular septal defect due to the left-to-right shunting of blood, which contributes to
hypertrophy of the infant's heart muscle.
Question - 13
A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury.
Which of the following interventions should the nurse include in the plan?
Answer: Implement seizure precautions for the infant. An infant who has an epidural hematoma
is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for
the child.
Question - 14
A nurse is caring for an adolescent who received a kidney transplant. Which of the following
findings should the nurse identify as an indication the adolescent is rejecting the kidney?
Answer: Serum creatinine 3.0 mg/dL. Creatinine is a byproduct of protein metabolism and is
excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can
be an indication that the kidneys are not functioning. The nurse should identify that the
adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0
mg/dL for an adolescent and can indicate rejection of the kidney.
Question - 15
A nurse in an emergency department is performing an admission assessment on a 2 week-old
male newborn. Which of the following findings is the priority for the nurse to report to the
provider?
Answer: Substernal retractions. When using the airway, breathing, and circulation approach to
client care, the nurse should determine that the priority finding to report to the provider is
substernal retractions. This finding indicates the newborn is experiencing increased respiratory
effort, which could quickly progress to respiratory failure.
Question - 16
A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse
that he cannot cope anymore and has decided to move out of the house. Which of the following
statements should the nurse make?
Answer: "Let's talk about some of the ways you have handled previous stressors in your life”.
This statement offers a general lead to allow the parent to express their feelings and previous
actions when faced with stressful situations. It also helps the parent to focus on ways that they
can cope with the current situation.
Question - 17
A nurse in an emergency department is caring for an adolescent who has severe abdominal pain
due to appendicitis. Which of the following locations should the nurse identify as McBurney's
point?
Answer: The nurse should identify this area of the client's abdomen as McBurney's point. This
area of the right lower quadrant located about two-thirds of the way between the umbilicus and
the client's anterosuperior iliac spine is the area where a client who has appendicitis is most
likely to report pain and tenderness.
Question - 18
A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy.
Which of the following lab values should the nurse report to the provider?
Answer: Hgb 8.5 g/dL. A child receiving chemotherapy is at risk for anemia due to the
chemotherapy effects on the blood-forming cells of the bone marrow. The development of
anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse
should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10
to 15.5 g/dL for a 7-year-old child and should be reported to the provider.
Question - 19
A nurse is caring for a 15 year-old client who is married and is scheduled for a surgical
procedure. The client asks, "who should sign my surgical consent?" Which of the following
responses should the nurse make?
Answer: "You can sign the consent form because you are married”. The nurse should inform the
adolescent that marriage gives adolescents the legal right to consent to surgical procedures and
sign other legal documents that they would not otherwise be able to sign due to their age.
Question - 20
A nurse is assessing a 4-year-old child at a well-child visit. Which of the following
developmental milestones should the nurse expect to observe?
Answer: Cuts an outlined shape using scissors. The nurse should recognize that an expected
developmental milestone of a 4-year-old child is using scissors to cut out a shape.
Question - 21
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following
actions should the nurse implement for infection control?
Answer: Have a designated stethoscope in the infant's room. The nurse should initiate droplet
precautions for an infant who has RSV because the virus is spread by direct contact with
respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a
stethoscope, should be placed in the infant's room.
Question - 22
A nurse in an emergency department is caring for a school-age child who has appendicitis and
rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the
nurse take?
Answer: Give morphine 0.05mg/kg IV. A pain level of 7 on a scale of 0 to 10 is considered
severe. The nurse should administer an analgesic medication for pain relief.
Question - 23
A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse
should identify that which of the following findings in an indication of early septic shock?
Answer: Temperature 39.1° C (102.4° F). The nurse should identify that a temperature of 39.1°
C (102.4° F) is above the expected reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10year-old child. The nurse should expect a child who has early septic shock to have a fever and
chills.
Question - 24
A school nurse is assessing an adolescent who has multiple burns in various stages of healing.
Which of the following behaviors should the nurse identify as a possible indication of physical
abuse?
Answer: Denies discomfort during assessment of injuries. The nurse should suspect child
maltreatment in the form of physical abuse if the adolescent has a blunted response to painful
stimuli or injury.
Question - 25
A nurse is caring for a 15 year-old client following a head injury. Which of the following
findings should the nurse identify as an indication that the child is developing syndrome of
inappropriate antidiuretic hormone secretion (SIADH)?
Answer: Mental confusion. A child who has a head injury can develop SIADH as a result of
altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of
antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due
to overhydration. As the hyponatremia becomes more severe, mental confusion and other
neurologic manifestations such as seizures can occur.
Question - 26
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the
following findings should the nurse expect?
Answer: • Ankle clonus
• Exaggerated stretch reflexes
• Contractures
Question - 27
A nurse in a provider's office if preparing to administer immunizations to a toddler during a wellchild visit. Which of the following actions should the nurse plan to take?
Answer: Withhold the measles, mumps, and rubella (MMR) vaccine. The nurse should
recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for
receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not
receive this vaccine.
Question - 28
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings
should the nurse expect?
Answer: A unilateral rib hump. When assessing an adolescent for scoliosis, the school nurse
should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or Cshaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or
pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be
congenital in nature.
Question - 29
A nurse is caring for a preschooler whose father is going home for a few hours while another
relative stays with the child. Which of the following statements should the nurse make to explain
to the child when their father will return?
Answer: "Your daddy will be back after you eat”. Preschoolers make sense of time best when
they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the
child comprehends time best when it is explained to them in relation to an event they are familiar
with, such as eating.
Question - 30
The nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV
catheter. When preparing to discontinue the IV fluids and catheter, which of the following
actions should the nurse plan to take?
Answer: First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV
tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over
the catheter insertion site.
Question - 31
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the
following actions should the nurse take during the immediate postictal period?
Answer: Place the child in a side-lying position. The nurse should place the child in a side-lying
position to prevent aspiration.
Question - 32
A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the
following statements by the guardian indicates an understanding of the teaching?
Answer: "I should secure the car seat using lower anchors and tethers instead of the seat belt”.
Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an
infant's car seat in the vehicle. This system provides anchors between the front cushion and the
back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be
used.
Question - 33
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract
infection. Which of the following findings should the nurse identify as a manifestation of
pertussis?
Answer: Dry, hacking cough. The nurse should identify that a dry, hacking cough is a
manifestation of pertussis. This disease usually begins with indications of an upper respiratory
tract infection, which includes a dry, hacking cough that is sometimes more severe at night.
Question - 34
A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following
actions should the nurse plan to take?
Answer: Administer the immunization using a 24-gauge needle. The nurse should administer an
immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of
pain the child experiences.
Question - 35
The nurse is providing discharge teaching to the parent of a child who is 1 week postoperative
following a cleft palate repair. For which of the following members of the inter professional team
should the nurse initiate a referral?
Answer: Speech therapist. The nurse should initiate a referral for a speech therapist for a child
who is postoperative following a cleft palate repair. A child who has a cleft palate will require
speech therapy immediately following the repair to support speech development and future
articulation.
Question - 36
A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school aged child
who weights 75 lbs. Available is atomoxetine 40 mg/capsule. How many capsules should the
nurse administer per day?
Answer: 1 capsule
Question - 37
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the
following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
Answer: Flank pain. The nurse should recognize that flank pain is caused by the breakdown of
RBCs and is an indication of a hemolytic reaction to the blood transfusion.
Question - 38
A nurse in the emergency department is caring for a toddler who has a partial thickness burns on
their right arm. Which of the following actions should the nurse take?
Answer: Cleanse the affected area with mild soap and water. The nurse should wash the affected
area with mild soap and water to remove any loose tissue that could cause infection.
Question - 39
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the
sound as which of the following?
Answer: Tachypnea. The nurse should identify the sound heard during auscultation as
tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with
anxiety, fever, metabolic acidosis, or severe anemia.
Question - 40
A nurse is reviewing the lumbar puncture results of a school-age child suspected of having
bacterial meningitis. Which of the following results should the nurse identify as a finding
associated with bacterial meningitis?
Answer: Increased protein concentration. The nurse should identify that an increased protein
concentration in the spinal fluid is a finding that can indicate bacterial meningitis.
Question - 41
A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following
manifestations should the nurse report to the provider?
Answer: Respiratory rate 45/min. The nurse should identify that a respiratory rate of 45/min is
above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate
respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this
finding to the provider.
Question - 42
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of
the tibia. The nurse should identify that which of the following statements by the parents
indicates an understanding of the teaching?
Answer: "My child will receive antibiotics for several weeks”. The nurse should instruct the
parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be
indicated if the antibiotics are not successful.
Question - 43
A nurse is providing teaching about social development to the parents of a preschooler. Which of
the following play activities should the nurse recommend for the child?
Answer: Playing dress-up. The nurse should instruct the parents that at the preschool age, play
should focus on social, mental, and physical development. Therefore, playing dress-up is a
recommended play activity for this child.
Question - 44
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe
dehydration. The nurse should identify that which of the following laboratory values indicates
effectiveness of the current treatment?
Answer: Sodium 140 mEq/L. The nurse should identify that a sodium level of 140 mEq/L is
within the expected reference range of 134 to 150 mEq/L and indicates the current treatment
regimen the infant is receiving for dehydration is effective.
Question - 45
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound
debridement following a burn injury. Which of the following actions should the nurse take prior
to the procedure?
Answer: Administer an analgesic to the child. Hydrotherapy for debridement of a wound is an
extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it
leads to reduced physiological demands on the body caused by stress and decreases the
likelihood of children developing depression and post-traumatic stress disorder.
Question - 46
A charge nurse in an emergency department is preparing an in-service for a group of newly
licensed nurses on the clinical manifestations of child maltreatment. Which of the following
manifestations should the charge nurse include as suggestive of potential physical abuse?
Answer: Symmetric burns of the lower extremities. The nurse should include that symmetric
burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic
of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.
Question - 47
A nurse is caring for a school-age child who in in Buck's traction following a leg fracture 24 hr
ago. Which of the following actions should the nurse take?
Answer: Assess peripheral pulses once every 4 hr. Buck's traction is a type of skin traction that
can be used to immobilize extremities prior to surgery. The nurse should provide frequent
neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The
nurse should monitor and report signs of neurovascular impairment in the extremities such as
cyanosis, edema, pain, absent pulses, and tingling.
Question - 48
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the
following actions should the nurse plan to take?
Answer: Schedule the toddler for a yearly rescreening. The nurse should schedule the toddler for
a lead level rescreening in 1 year and educate the family on ways to prevent exposure.
Question - 49
A nurse is receiving change-of-shift report on four children. Which of the following children
should the nurse see first?
Answer: A school-age child who has sickle cell anemia and reports decreased vision in the left
eye. When using the urgent vs. nonurgent approach to client care, the nurse should determine the
priority finding is a report of decreased vision in the left eye. This finding indicates that the child
is experiencing a vaso- occlusive crisis and should be reported to the provider immediately.
Therefore, the nurse should see this child first.
Question - 50
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse
should instruct the parent to apply which of the following to the affected area?
Answer: Zinc oxide. Diaper dermatitis is a common inflammatory skin disorder caused by
contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling,
blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the
irritants allows the skin to heal.
Question - 51
A nurse is caring for a school-age child who is receiving chemotherapy and is severely
immunocompromised. Which of the following actions should the nurse take?
Answer: Screen the child's visitors for indications of infection. A child who is severely
immunocompromised is unable to adequately respond to infectious organisms, resulting in the
potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for
indications of infection.
Question - 52
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of
dehydration. Which of the following findings is the nurses priority?
Answer: Tachypnea. When using the airway, breathing, and circulation approach to client care,
the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being
unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.
Question - 53
A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus.
Which of the following statements by the child indicates an understanding of the teaching?
Answer: "I will give myself a shot of regular insulin 30 minutes before I eat breakfast”. The
child should administer regular insulin 30 min before meals so that the onset coincides with food
intake.
Question - 54
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome
(SIDS). Which of the following instructions should the nurse include?
Answer: "Give the infant a pacifier at bedtime”. The nurse should inform the parent that
protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is
sleeping.
Question - 55
The nurse is assessing a school-age child who has peritonitis. Which of the following findings
should the nurse expect?
Answer: Abdominal distension. The nurse should identify that abdominal distention is an
expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall.
This inflammation in the abdomen, along with the ileus that develops, causes abdominal
distention. Other manifestations include chills, irritability, and restlessness.
Question - 56
The nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The
nurse should identify that which of the following findings indicates a need to assess the toddler
for hearing loss?
Answer: The toddler received tobramycin during a hospitalization 2 weeks ago. The nurse
should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause
mild to moderate hearing loss, and should assess the toddler for a hearing impairment.
Question - 57
A nurse is providing teaching to the parent of a school-age child who has a new prescription for
oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the
nurse include?
Answer: "Shake the medication prior to administration”. The nurse should instruct the parent to
shake the medication prior to administration to disperse the medication evenly within the
suspension.
Question - 58
A nurse is admitting a school-age child who has Pertussis. Which of the following actions should
the nurse take?
Answer: Initiate droplet precautions for the child. The nurse should initiate droplet precautions
for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through
contact with infected large-droplet nuclei that are suspended in the air when the child coughs,
sneezes, or talks.
Question - 59
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration.
Which of the following nutritional items should the nurse offer to the toddler?
Answer: Oral rehydration solution. A toddler who has acute diarrhea should consume an oral
rehydration solution to replace electrolytes and water by promoting the reabsorption of water and
sodium. This promotes recovery from dehydration.
Question - 60
A nurse in an emergency department is caring for a school-age child who is experiencing an
anaphylactic reaction. Which of the following is the priority action by the nurse?
Answer: Administer epinephrine IM to the child. When using the urgent vs. nonurgent approach
to client care, the nurse should determine that the priority action is administering epinephrine IM
to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and
vasodilation. This is an emergency because ultimately this causes decreased blood return to the
heart.
